DIETETIC  TREATMENT  OF 

TUBERCULOSIS 


BY 

JOHN  J.  LLOYD,  JR.,  M.  D., 

Catawba  Sanatorium,  Va. 


WILLIAMS  PRINTING  COMPANY, 
Richmond,  Va. 


6,14.5  41 

Ul7cL 


[Reprinted  from  the  Virginia  Medical  Semi-Monthly,  Nov.  21, 1913.] 


DIETETIC  TREATMENT  OF  TUBERCULOSIS.* 

By  JOHN  J.  LLOYD,  JR.,  M.  D.,  Catawba  Sanato- 
rium, Va. 


In  considering  this  phase  of  treating  tuber- 
culosis, it  will  be  well  to  recall  that  one  of  the 
prime  characteristics  of  the  disease  is  rapid 
and  progressive  loss  of  weight.  To  repair  that 
already  having  taken  place  and  to  prevent 
further  loss  is  one  of  the  essential  factors  of 
treatment. 

No  rigid  rules  as  to  dietary  can  be  laid  down, 
for  cases  differ  so  widely  that  each  must  be 
treated  on  its  own  merits.  An  acute  tuber- 
culosis in  a young  adult  requires  very  different 
handling  from  an  early  case  in  one  who  is  up 
to  his  standard  weight  and  shows  only  slight 
symptoms.  A blacksmith  and  a banker  will 
hardly  eat  with  relish  the  same  dietary,  nor  will 
a woman  of  sedentary  habits  require  the  same 
food  as  a day  laborer.  It  is  necessary  to  furnish 
each  patient  with  a well  balanced  ration  and 
this  must  be  based  largely  upon  the  taste  and 
previous  habits  as  to  eating. 

The  average  healthy  adult  on  moderate  ex- 
ercise has  been  proven  to  require  about  3000 
calories  of  food  per  day.  Men  require  slightly 
more  in  proportion  to  weight  than  do  women. 
Young  people  require  proportionately  more  than 


♦Read  before  the  forty-fourth  annual  meeting  of  the 
Medical  Society  of  Virginia,  at  Lynchburg,  October 
21-24,  1913,  as  a part  of  the  Symposium  on  Tuberculosis. 


older,  this  because  the  younger  the  cell  the 
greater  the  avidity  and  rapidity  of  oxydizing 
food  for  tissue  use.  Thin  people  require  con- 
siderably more  than  fat,  due  to  more  rapid  loss 
of  heat  through  radiation. 

The  human  race  has  profited  by  years  of  ex- 
perience, instinct  and  taste  in  choosing  a dietary 
suitable  and  sufficient  for  the  maintenance  of 
health.  The  standard  dietary  (Hutchinson)  con- 
sisting of  125  grams  proteid,  50  grams  fat  and 
500  grams  carbohydrate,  based  upon  experi- 
mentation and  yielding  3000  calories,  is  closely 
approximated  by  the  meals  served  on  many 
well  kept  tables.  Generally  speaking,  fat  and 
carbohydrate  can  be  substituted  one  for  the  other 
to  large  extent;  hence,  the  proportion  of  the 
two  and  the  form  in  which  they  occur  depend 
largely  upon  the  financial  condition  and  taste 
of  the  individual. 

It  is  a recognized  fact  that  recovery  from  any 
infection  depends  upon  the  establishment  of  an 
immunity  toward  this  infection  and  that  the  re- 
sult of  continued  under-feeding  is  to  produce 
a condition  of  lowered  resistance  to  disease.  Un- 
der-nourished cells  must  maintain  life  first,  and 
what  energy  they  have  to  spare  can  be  used  in 
producing  immune  bodies ; therefore,  we  must 
endeavor  to  furnish  an  extra  supply  of  nourish- 
ment to  the  cells  in  order  that  they  in  turn  may 
produce  the  immunity  necessary  for  recovery. 

The  method  of  forced  feeding  so  much  in  vo- 
gue a few  years  back  has,  happily  for  the  pa- 
2 


tient , fallen  into  well  deserved  disrepute.  To 
overload  continually  a digestive  system  already 
embarrassed  by  general  toxemia  and  under-nour- 
ishment was  only  heaping  insult  upon  injury, 
and  was  the  direct  cause  of  converting  many 
hopeful  into  hopeless  cases,  or  at  least  of  ma- 
terially retarding  their  progress  toward  recov- 
ery. The  day  of  stuffing  patients  simply  be- 
cause they  happen  to  have  tuberculosis  is  past 
and  we  need  only  mention  it  to  condemn  it. 

Let  our  aim  be  to  supply  all  the  nourishment 
the  patient  needs  in  health  and  a little  extra  on 
account  of  his  disease  and  endeavor  to  increase 
the  bodily  weight  to  its  previous  normal,  before 
tuberculosis  became  active,  or  slightly  above 
and  keep  it  there ; in  other  words  to  bring  about 
a condition  of  slightly  over-nourished  cells  so 
that  they  may  have  a good  balance  on  deposit  to 
spend  in  ridding  the  body  of  its  infection.  Ex- 
cessive weight  gain  is  neither  essential  nor  de- 
sirable but  a return  to  the  normal  or  slightly 
above  is  to  be  desired. 

Experience  has  conclusively  proven  that  the 
tuberculous  patient  not  only  tolerates  but  re- 
quires a considerable  increase  in  the  proteid  and 
fat  ration.  Additional  proteid  is  necessary  to 
repair  the  tissue  waste  and  more  fat  to  save  heat 
loss.  As  the  carbohydrate  is  the  bulky  food  con- 
stituent, the  amount  is  slightly  reduced  and  its 
equivalent  made  up  in  proteid  and  fat  which 
should  preferably  be  of  animal  origin,  as  this 
class  of  these  foods  has  been  found  more  valu- 
3 


able  in  tuberculosis  than  that  of  vegetable  ori- 
gin. The  proteid  content  is  best  supplied  by 
meat,  eggs  and  milk — the  fat  by  milk,  cream, 
butter  and  the  yolk  of  eggs  and  bacon.  Hence 
it  will  be  seen  that  if  we  prescribe,  in  addition 
to  three  well  balanced  meals,  three  pints  of 
milk  with  a slight  increase  of  meat  and  butter, 
the  proper  amount  of  food  is  obtained. 

For  instance,  a dietary  such  as  the  following 
furnishes  the  necessary  quantities  of  food  con- 
stituents for  a patient  with  unimpaired  diges- 
tion : 

Breakfast — 8 A.  M. — Fresh  fruit,  cereal, 
breakfast  bacon,  2 eggs,  soft  boiled  or  poached, 
biscuits,  coffee,  milk  and  butter. 

Lunch — 10:30  A.  M. — Glass  of  milk. 

Dinner — 1 P.  M. — Soup,  roast  beef,  mashed 
potatoes,  stewed  tomatoes,  boiled  spinach,  corn 
pones,  gelatine  jelly  and  cake,  milk  and  butter. 

Lunch — 4 P.  M. — Glass  of  milk. 

Supper — 6 P.  M. — Creamed  chicken,  grits, 
hot  rolls,  cocoa  or  hot  tea,  milk  and  butter. 

Lunch — 9 P.  M. — Glass  of  milk 

The  above  is  # only  an  illustration  of  many 
combinations  which  may  be  made  at  moderate 
cost.  Where  cost  must  be  still  more  considered, 
the  proteid  ration  may  be  furnished  by  using 
the  cheaper  cuts  of  meat  and  the  fat  content  fur- 
nished in  the  form  of  fat  bacon  and  oleomar- 
garine. 

In  feeding  children  the  requirements  of  the 
case  are  different.  It  must  be  borne  in  mind 
4 


that  children  require  proportionately  more  food 
for  their  weight  than  do  adults.  Children  also 
have  a considerably  greater  tolerance  for  fats, 
and  therefore  they  should  receive  more  milk, 
butter,  bacon,  etc.,  proportionately  than  the 
adult. 

Open  air  treatment  goes  hand  in  hand  with 
dietetic  treatment,  for  life  in  the  open  air 
sharpens  the  appetite,  stimulates  the  digestion 
and  lessens  the  toxemia.  If  to  these  two  is 
added  rest,  while  symptoms  are  present,  we  have 
the  tripod  upon  which  recovery  depends.  It  is 
hard  to  overestimate  the  benefits  of  rest  in 
tuberculosis,  and  especially  its  effect  upon  the 
digestive  system.  We  have  repeatedly  seen  rest 
in  bed  overcome  long  standing  dyspepsia, 
thus  enabling  the  patient  to  consume 
and  assimilate  a proper  amount  of  food. 
The  body  at  rest  requires  considerably 
less  food  than  when  at  work  to  mantain  health ; 
consequently  we  can  see  the  desirability  of  keep- 
ing patients  quiet  in  order  that  the  least  pos- 
sible amount  of  waste  and  the  maximum  amount 
of  nourishment  be  produced. 

So  much  for  generalities — now  to  consider 
the  indications  in  feeding  patients  in  the  differ- 
ent stages  of  the  disease  and  in  dealing  with 
complications.  In  the  very  early  case,  before 
symptoms,  especially  derangement  of  digestion, 
are  marked,  very  little  alteration  of  a general 
home  diet  is  necessary.  If  the  patient’s  weight 
is  about  normal  and  he  be  put  on  the  rest  treat- 


ment  and  given  three  good  meals  and  three  pints 
of  milk  in  addition,  he  will  get  more  than  the 
required  amount  for  the  body  in  health,  and 
therefore  enough  food  for  his  needs.  Gases 
diagnosed  at  this  stage  are  unfortunately  very 
few,  for  the  patient  does  not  feel  sick  enough 
to  see  a physician  or  the  disease  is  not  recog- 
nized at  this  time. 

In  much  the  larger  number  of  instances  the 
case  is  not  diagnosed  until  the  moderately  ad- 
vanced or  far  advanced  stage  is  reached,  when 
symptoms  are  much  more  pronounced. 

Indigestion  and  lack  of  appetite  are  among 
the  conditions  we  most  often  have  to  face  in 
feeding  patients.  Total  loss  of  appetite  amount- 
ing to  intense  disgust  at  sight  of  food  is  not 
at  all  uncommon.  At  the  outset  of  treatment, 
after  first  satisfying  ourselves  of  the  fact,  we 
must  convince  the  patient  that  the  gastric  dis- 
turbance is  a symptom  of  his  disease;  that  his 
stomach  and  intestines  are  not  organically  dis- 
eased, but  that  the  whole  body  is  suffering  from 
under-nourishment ; that  the  digestive  organs 
share  this  weakness,  but  that  after  a few  weeks 
of  better  feeding  his  digestive  functions  will 
improve.  This  is  rather  a hard  task  at  times, 
for  these  cases  not  infrequently  have  thought  for 
months  they  were  suffering  from  “stomach 
trouble”  and  have  as  a consequence  cut  off  one 
article  of  food  after  another,  until  nothing  but 
the  lightest  diet  of  slops  is  being  taken. 

They  will  often  in  a few  days  be  able  to 

6 


take  and  retain  a fair  quantity  of  nourishing 
food  if  due  persuasion  and  tact  are  used  and 
the  food  served  tastefully  and  in  small  quanti- 
ties. Of  course,  cases  of  this  kind  should  he 
kept  constantly  in  bed,  and  the  first  day  or  two 
probably  only  a milk  diet  prescribed.  The  rest 
in  bed,  by  reducing  the  absorption  and  thus  les- 
sening the  toxemia,  will,  in  a large  measure,  re- 
lieve the  embarrassment  of  the  digestive  organs 
and  enable  them  to  take  up  their  proper  function. 
If  the  digestive  system  is  tolerant,  we  may  push 
the  patient  by  adding  little  by  little,  until  after 
a week  or  so  he  is  taking  full  meals.  At  times 
this  return  to  larger  quantitites  of  food  is  accom- 
panied by  considerable  distress,  which  may  be 
alleviated  somewhat  by  proper  medicinal  meas- 
ures, but  our  course  of  returning  to  full  meals 
must  be  persisted  in  if  possible. 

Febrile  patients  are  not  exceptions  to  this 
rule,  and  if  they  can  digest  the  full  diet  in  spite 
of  the  fever,  it  should  be  allowed.  Those  pati- 
ents who  can  assimilate  the  general  diet  improve 
much  more  rapidly  than  those  who,  perforce  of 
digestive  disturbance,  are  compelled  to  eat  only 
limited  articles  of  food.  In  case  the  digestion 
is  especially  bad  at  the  height  of  the  fever,  a 
light  meal  or  liquids  may  be  given  at  this  time, 
and  the  large  meals  given  before  and  after  the 
temperature  has  risen.  Increased  nutrition 
usually  produces  a drop  in  temperature,  and 
should  it  not  do  so,  then  the  case  is  indeed  a 
difficult  one  to  benefit. 


( 


Ill  feeding  cases  with  impaired  digestion  it 
is  well  to  insist  upon  their  eating  the  staple 
foods  and  allow  sugars  and  pastry  in  very  small 
quantities,  if  at  all.  Sweets  and  pastries, 
though  they  may  be  palatable  at  the  time,  will 
almost  surely  result  in  the  formation  of  gas  and 
hyperacidity,  with  probably  nausea  and  vomit- 
ing and  total  loss  of  appetite.  Fried  foods  of 
all  kind"-  are  bad  and  meats  are  more  digestible 
if  cooked  without  grease  and  beef  served  rare. 
The  bulky  foods  are  to  be  avoided  and  the  diet 
made  as  concentrated  as  is  possible. 

When  vomiting  occurs  after  eating,  when  not 
produced  by  paroxysms  of  coughing,  gastric 
lavage  or  withholding  food  for  twelve  to 
twenty-four  hours  with  attention  to  the  bowel 
movements,  will  often  bring  relief.  A glass  of 
hot  water  taken  on  rising  is  a splendid  thing 
for  the  stomach,  and  is  beneficial  in  many 
cases. 

Diarrhoea,  so  often  a symptom  of  tubercu- 
losis of  the  intestines,  is  a difficult  matter  to 
combat.  Here  the  indication  is  to  place  as 
little  work  as  possible  on  the  diseased  intestines^ 
but  at  the  same  time  properly  nourish  the 
patient.  To  meet  this  end  the  food  served  should 
consist  of  concentrated  foods,  bulky  articles  be- 
ing religiously  avoided.  Milk,  eggs  and  meat 
are  our  main  foods  for  this  condition,  and  must 
be  served  in  many  different  ways,  as  our  aim 
is  to  persist  in  this  dietary  as  long  as  necessary, 
and  at  the  same  time  retain  the  appetite.  If  the 
8 


indigestion  persists  under  the  above  diet,  it  will 
be  necessary  to  resort  to  a strictly  liquid  diet, 
using  perhaps  predigested  foods.  As  improve- 
ment in  the  condition  takes  place  the  bulkier 
articles  may  be  slowly  added  to  the  menu,  and 
the  patient  gradually  placed  on  full  diet. 

Acute,  intercurrent  disorders  are  dieted  just 
as  under  any  other  conditions,  but  we  should 
keep  in  mind  the  fact  that  the  patient  has 
tuberculosis,  and  therefore  bears  starvation 
badly. 

When  the  upper  portion  of  the  larynx  or  the 
pharynx  is  involved  we  have  a most  distressing 
condition  to  meet.  Deglutition  is  very  often  im- 
possible without  previous  local  anesthesia  of  the 
pharynx,  and  even  then  the  patient  becomes 
easily  strangled.  Here  again  concentrated  food 
is  indicated  in  order  to  save  the  patient  pain. 
If  swallowing  liquids  is  very  difficult,  and 
frequently  liquids  produce  most  difficulty,  the 
patient  can  often  swallow  much  better  if  lying 
flat  on  the  abdomen. 

If  the  cough  is  so  exasperating  as  to  effect 
the  appetite,  especially  if  it  interferes  with  the 
proper  rest  at  night,  appropriate  measures  for 
its  relief  are  indicated. 

The  dietetic  treatment  of  hemorrhage  is  of 
considerable  importance  in  that  the  indications 
are  to  reduce  the  liquid  content  to  the  minimum 
and  avoid  bulky  and  stimulating  foods.  Hot 
foods  are  stimulating,  hence  all  food  is  to  be 
served  cold.  For  the  first  twenty-four  hours 
9 


no  food  whatever  should  be  given  if  the  hemor- 
rhage is  a large  one.  Onlv  sufficient  liquid  to 
allay  thirst  and  prevent  discomfort  is  allowed, 
and  this  preferably  as  finely  crushed  ice  in 
small  quantities.  At  the  end  of  twenty-four 
hours  the  diet  should  be  of  small  bulk,  served 
cold,  at  slightly  shorter  intervals  than  before  the 
occurrence  of  the  hemorrhage,  the  liquid  content 
kept  to  a minimum  and  only  milk  and  water 
allowed  as  beverages.  After  continuing  this 
until  all  fresh  blood  has  disappeared  from  the 
sputum,  the  general  diet  may  then  be  gradually 
replaced.  As  the  recurrence  of  hemorrhage  is 
often  directly  due  to  indiscretion  in  diet,  this 
should  be  carefully  considered  in  dealing  with 
the  condition. 

In  tuberculosis  we  must  bear  in  mind  the  Yact 
that  the  condition  is  one  calling  for  the  maxi- 
mum amount  of  nourishment  with  the  least 
possible  embarrassment  to  the  organs  of  diges- 
tion and  excretion.  We  should  also  remember 
that  we  are  dealing  with  a chronic  process  re- 
quiring years  for  recovery,  and  it  is,  therefore, 
necessary  to  husband  ' at  every  point  the 
strength  of  the  patient  for  the  fight.  Bad 
advice  as  to  the  food  necessary  will  produce 
bad  results.  We  must  be  specific  in  giving 
advice  as  to  what  articles  are  allowed  and  what 
forbidden,  and,  in  addition,  we  must  prescribe 
the  quantities  to  be  consumed.  In  the  manage- 
ment of  cases  in  private  practice,  there  is  noth- 
ing so  helpful  to  both  patient  and  physician 
10 


as  a careful  daily  record  kept  by  the  patient 
as  to  his  hours  of  rest,  etc.,  the  exact  amount  of 
food  consumed  and  at  what  hours.  Regularity 
of  meals  is  one  of  the  great  necessities  in  feed- 
ing patients,  and  eating  when  not  fatigued  is 
of  equal  importance  with  regularity.* 

In  conclusion,  I should  like  to  add  that,  how- 
ever well  we  may  feed  our  patient  or  how  many 
hours  he  spends  daily  in  the  open  air  will  not 
effect  the  result  nearly  so  much  as  if  to  proper 
food  and  fresh  air  we  add  REST  while  the 
disease  is  still  active . 


11 


- s 


